Over the past two decades, thousands of studies have demonstrated that Blacks receive lower quality medical care than Whites, independent of disease status, setting, insurance, and other clinically relevant factors. Despite this, there has been little progress towards eradicating these inequities. Almost a decade ago we proposed a conceptual model identifying mechanisms through which clinicians’ behavior, cognition, and decision making might be influenced by implicit racial biases and explicit racial stereotypes, and thereby contribute to racial inequities in care. Empirical evidence has supported many of these hypothesized mechanisms, demonstrating that White medical care clinicians: (1) hold negative implicit racial biases and explicit racial stereotypes, (2) have implicit racial biases that persist independently of and in contrast to their explicit (conscious) racial attitudes, and (3) can be influenced by racial bias in their clinical decision making and behavior during encounters with Black patients. This paper applies evidence from several disciplines to further specify our original model and elaborate on the ways racism can interact with cognitive biases to affect clinicians’ behavior and decisions and in turn, patient behavior and decisions. We then highlight avenues for intervention and make specific recommendations to medical care and grant-making organizations.

This article applied dual process models of stereotyping to illustrate how various psychological mechanisms may lead to unintentional provider bias in decisions about pain treatment. Stereotypes have been shown to influence judgments and behaviors by two distinct cognitive processes, automatic stereotyping and goal-modified stereotyping, which differ both in level of individual conscious control and how much they are influenced by the goals in an interaction. Although these two processes may occur simultaneously and are difficult to disentangle, the conceptual distinction is important because unintentional bias that results from goal-modified rather than automatic stereotyping requires different types of interventions. We proposed a series of hypotheses that showed how these different processes may lead providers to contribute to disparities in pain treatment: 1) indirectly, by influencing the content and affective tone of the clinical encounter; and 2) directly, by influencing provider decision making. We also highlighted situations that may increase the likelihood that stereotype-based bias will occur and suggested directions for future research and interventions.

Our findings point to the importance of research and intervention strategies addressing the ways in which providers' beliefs about patients mediate disparities in treatment. In addition, they highlight the need for discourse and consensus development on the role of social factors in clinical decisionmaking.

No abstract